Provider Demographics
NPI:1578236055
Name:FERNANDEZ GIL, TAIS (PTA)
Entity Type:Individual
Prefix:MISS
First Name:TAIS
Middle Name:
Last Name:FERNANDEZ GIL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 SW 152ND AVE APT 29
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2392
Mailing Address - Country:US
Mailing Address - Phone:305-303-0392
Mailing Address - Fax:
Practice Address - Street 1:1790 SW 43RD WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33317-5701
Practice Address - Country:US
Practice Address - Phone:954-584-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29923225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant